Nocturnal Enuresis

Case

The parents of a seven year old boy bring their son to the office because he has rarely been dry at night. His four year old sister is always dry and they are very concerned. He doesn't wet his pants during the day. How would you evaluate this patient and advise this family?

Enuresis is involuntary voiding at night (bedwetting). It should be differentiated from daytime or diurnal enuresis. At the age of 5, approximately 85% of children will be dry at night. Afterwards, about 15% will improve per year and 1% of adults are still bedwetting. Boys are affected three times more than girls.

Secondary enuresis is defined as the onset of bedwetting after having been dry at night for 6 months prior to wetting the bed again. The incidence is between 3-8% of 5-12 year olds. About 15% resolve yearly in this group as well.

Pertinent history

Establish whether this is primary or secondary

Family history of enuresis- 40% incidence if one parent and 70% if both parents were enuretic

History of constipation or encopresis

Symptoms of UTI's

Any history of renal disease

Any symptoms of diabetes insipidus or mellitus

Voiding history- problems in daytime, number of times goes during the day, stream, difficulty starting and stopping

Emotional or behavioral symptoms

Neurologic symptoms- weakness, bowel control changes, gait changes

Physical exam

Examination of genitalia

Neurologic exam

Abdominal exam

Inspection of back and spinal column

Laboratory evaluation

urine analysis and culture

Etiology

Genetic

Bladder capacity and function- usually not an issue in primary enuresis

Deep sleeper- not a proven cause

Sleep apnea- there is an association of sleep apnea with large adenoids and tonsils and enuresis that may improve with T&A.

ADH secretion abnormalities have been suggested but never proven

Stress and psychogenic- never proven

Neurologic dysfunction- may be a delay in maturation. Some "soft" neurologic signs have been associated

Diet- not proven

Bacteriuria has been associated with secondary enuresis.

Management of Enuresis

Enuresis alarm.

A careful history and physical exam are very important in the evaluation of enuresis. Any treatment modality should include the parents as well as the child. Children should limit the intake of fluids before going to sleep and should void prior to going to bed. Waking the child at night is of little value and is disruptive to the entire family. De-emphasize the significance of the problem and point out that only 1% of adults are still enuretic. Make the child responsible for changing their bed clothes and sheets and bringing them to the laundry. Never punish and appreciate that you may be dealing with a child with poor self esteem.

Behavioral modification- keep a calendar of dry and wet nights and give stars or other small reward for dry nights. Bring chart to office on the next visit. Encourage the child. Have the child phone you and relate how they are doing.

Alarm systems- cost about $60 and successful if used properly and consistently. Compliance is a problem and staying on the alarm a problem. Alarm that hooks on to undergarment work well. May be used with DDAVP which jumps starts success because may take 3 weeks for alarm to show results. Then taper DDAVP.

Medications

Ditropan- successful if bladder function or sphincter problem.

Imipramine- May be useful but often when stop medicine child begins to wet again

DDAVP- very expensive and when stop child will often start to wet bed again. Useful for special occasions and for desperate families.